______________________________________ Event Date(s)_________________
______________________________________ ______________________ ____________________
TEMPORARY PERMIT LOCATION AND ZONING
Organization Name or Individual Applicant Event Date(s)
Event Type: Charitable Auction On-Premise Porcelain Container
Special Event* - Number of Consecutive days (up to 30):
*A special event is held on public streets, alleys, roads, sidewalks or highways and must be approved, by ordinance or resolution, by
the local governing body of any city, county or township where such special event is being held.
SECTION 1 – EVENT AREA: Complete this section for On-Premise and Special Events only.
In the space below, in ink, draw the floor plan and any outside areas included in the proposed event area where alcoholic liquor will be sold, served
or consumed. If the area is outside, it must show where the three-dimensional barriers will be located to define the event area; and, include nearby
streets for reference. Shade in the areas you DO NOT wish to be permitted.
SECTION 2 – CERTIFICATE OF CITY, TOWNSHIP OR COUNTY CLERK: (Completed by the clerk).
I HEREBY CERTIFY THAT THE PREMISES AT
Location Street Address City Zip
Inside the incorporated city limits Outside the city limits
within an area that complies with all applicable zoning regulations required by K.S.A. 41-2645(d)
located outside an incorporated city, in a township or county that is not zoned
LOCATION: government property private property public property CMB licensed premise
I declare under penalties of perjury that to the best of my knowledge and belief that Section 2 is true, correct and complete.
CLERK SIGNATURE DATE PHONE
PRINTED NAME City Clerk Township Clerk County
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